HIV Case Manager (Bilingual English/Spanish)

Open Door Family Medical Center provides health care and wellness programs to individuals and families in need throughout Westchester, Putnam and Ulster Counties. A pioneer Federally Qualified Health Center, Open Door provides more than 300,000 patient visits annually and serves nearly 60,000 individual patients who might not otherwise have access. Open Door offers integrated services and a holistic approach to building healthier communities. Primary medical care, dental care, integrated behavioral health care, clinical nutrition, wellness programs, and chronic disease management are the foundation of its clinical programs.

Founded as a free clinic in 1972, Open Door’s mission of building healthier communities through accessible, equitable, culturally competent health care has led to site and service expansions. Today, Open Door operates centers in Brewster, Mamaroneck, Mount Kisco, Ossining, Port Chester, and Sleepy Hollow, in addition to eight School-Based Health Centers in the Port Chester and Ossining School Districts, a mobile dental van in Mount Kisco, and a new dental practice in Saugerties, NY. For more information, please visit our website at www.opendoormedical.org.

Job Summary

As a Patient- Centered Medical Home (PCMH), Open Door Family Medical Center offers a range of case and care management programs designed to deliver comprehensive, coordinated, and patient centered care. With a focus on managing chronic conditions and improving health outcomes, these programs provide a personalized support to patients with the goal of reducing barriers by connecting enrollees with appropriate social and community services. The HIV Case Manager participates in a patient-focused, team-based approach and support patients enrolled in the following programs:

• HIV Case Management program which provides comprehensive case management services to people living with HIV/AIDS regardless of insurance status.
• The New York State Health Home Program (HH) which is specific for individuals with Medicaid who meet the program eligibility criteria.

Open Door’s Care Managers are part of the medical care team. The primary responsibilities of the HIV Case Manager include conducting assessments, developing care plans and engaging patients in receiving medical, behavioral health and social services.

Duties and Responsibilities

• Outreach individuals and engage them into case management services
• Conduct assessments to identify individualized needs related to psychosocial wellbeing, physical health and the social determinants of health; utilize standardized assessment tools; monitor needs on an ongoing basis
• Based on the findings from the assessments, collaborate with the patient and involved family members/caregivers to set up goals and develop a plan of care
• Coordinate and arrange for the provision of medical, behavioral health and social services
• Accompany members to appointments as needed with the goal of modeling and coaching on how to navigate medical/behavioral health visits with the aim of empowering individuals to become independent, effective health care consumers
• Provide concrete case management services to address barriers to care, including the social determinants of health
• Serve as a healthcare system navigator to ensure that patients can access crucial aspects of health care both internal and external to Open Door. Ensures that care is well coordinated and facilitates communication amongst medical providers
• Support members in adherence to treatment recommendations from medical and behavioral health providers; addresses medication adherence issues under the direction of HIV medical specialists
• Provide research-based education using one-on-one teaching, written and printed materials as well as computer and video instruction to assist members with understanding their HIV/AIDS as well as any other physical and behavioral health conditions (i.e. diabetes, asthma, hypertension)
• Assess patients’ confidence and abilities in managing their own health care and navigate the health and social care system
• Identify and refer members to available community-based resources and services including prescription assistance program(s); assist patients with applications, insurance, paperwork as needed
• Serve as a liaison between HIV medical specialists and patients
• Case conferences with HIV medical specialist and follows up with patient and/or HIV medical specialist on identified matters
• Document all patient care activities in the electronic medical record and other data bases when applicable in compliance with the guidelines provided by Open Door and following the Policies and Procedures established by the Joint Commission and the DOH for those enrolled in Health Home
• Complete Monthly Billing Questionnaires (MBQs) for those enrolled in HH
• Participate in patient support group meetings
• Discuss advance directives with members and their families or caregivers
• Travel to meet with members at their medical/behavioral health appointments, public or community settings, and/or conduct home visits

• Meet annual mandatory trainings requirements, including the completion of40 hours annual trainings required for HH staff working with PLWH
• Establish and maintain active and positive linkages with other communities agencies and participates in inter-agency meetings as assigned by supervisor
• Represent Open Door at community health fairs and community outreach activities to ensure awareness of HIV program services, increase appropriate referrals for HIV prevention counseling and provide current information on HIV and STI prevention and care
• Participate in staff development programs, educational activities, seminars, and training opportunities
• Participate in team meetings, Quality Improvement meetings and other initiatives as applicable
• Conduct other data tracking and reporting activities as assigned
• Utilize evidence-based and best-practice techniques on a daily basis in accordance with training (e.g., teach-back method, Motivational Interviewing and SMART [specific, measurable, attainable, realistic, and timely] goal setting)
• Other duties as assigned

• Informs the Senior Manager, HIV Care & Prevention Programs and the Manager, Case Management Programs of any problems that may affect quality and standards of patient services
• Fosters good communication between Open Door and patients by returning all patient telephone requests in a timely manner
• Demonstrates ability to function in a culturally sensitive manner within Open Door’s philosophy and mission
• Ensures communication among Open Door departments through individual, small group, or department meetings

Qualifications

• Master’s degree in social work or social sciences preferred.
• Bachelor's degree in health, human services, education, social work, or mental health required.
• Associate degree in health, human services, social work, mental health, or certification as RN or LPN and 2 years of qualifying experience will be considered.
• One year of experience serving individuals with HIV, history of mental illness, homelessness or substance abuse.
• Knowledge of/experience in case management and care coordination is preferred.
• Health education experience is preferred.
• Experience with electronic medical records is preferred.
• Fluent in English and Spanish
• Culturally competent/sensitive (racial, ethnic, linguistic, LGBTQ , physical ability, etc.) and committed to inclusive, multi-cultural programming
• Strong interpersonal skills including excellent active listening and clear oral communication skills
• Engaging, warm and caring personality, strong customer service, patient-centered orientation, empathetic and driven to assist patients
• Passionate about providing high quality care to PLWHA as well as low-income, under-served individuals and those lacking access to health care
• Able to function effectively as a member of an interdisciplinary team and committed to collaborative team-based care
• Proficient computer skills including Microsoft Office applications such as EXCEL
• Strong writing and reading skills
• Able to understand and follow detailed instructions
• Highly organized and self-directed, able to multi-task
• Flexible and exhibits the ability to adapt as situations evolved
• Comfortable working in a fast-paced, high accountability environment
• Able to understand and follow detailed instructions
• Effective in problem solving and exhibits excellent judgment and the ability to prioritize
• Must have valid NYS driving license and daily access to car
• Manual dexterity and regular hours at computer keyboard.
• Approximately 50% sitting and 50% walking/standing.
• Bending and lifting may be required.

There are many fantastic benefits to a career at Open Door Family Medical Centers. In addition to working to effect positive change in the health and lives of thousands of residents in our communities, Open Door offers its employees a stimulating, diverse and team-based work environment with comprehensive benefits including medical, dental, life insurance, flexible spending accounts, 401(k), generous paid time off, and educational assistance. Aside from excellent benefits, we offer a competitive salary, and annual bonuses based on organizational and individual objectives.

At Open Door, we enjoy working in a team-based, patient-centered environment and value the benefits of a diversified workplace that values our patients and the communities we serve. If you want to make a difference in the lives of thousands of patients and if thisposition speaks to your capabilities, experience and commitment to improve the health of our communities, please submit your resume and cover letter with salary requirements.

Open Door is an Equal Opportunity Employer